Provider Demographics
NPI:1952469207
Name:HERNANDEZ, SERGIO O (PT)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:O
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 STEVE REYNOLDS BLVD
Mailing Address - Street 2:BLDG G.
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3035
Mailing Address - Country:US
Mailing Address - Phone:770-622-2532
Mailing Address - Fax:770-622-2534
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD
Practice Address - Street 2:BLDG G.
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3035
Practice Address - Country:US
Practice Address - Phone:770-622-2532
Practice Address - Fax:770-622-2534
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA03810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00811148CMedicaid
GA00811148EMedicaid